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Robin Hanson sometimes writes about how health care is a form of signaling, trying to spend money to show you care about someone else. I think he’s wrong in the general case – most people pay their own health insurance – but I think he’s spot on in the case of families caring for their elderly relatives. The hospital lawyer mentioned during orientation that it never fails that the family members who live in the area and have spent lots of time with their mother/father/grandparent over the past few years are willing to let them go, but someone from 2000 miles away flies in at the last second and makes ostentatious demands that EVERYTHING POSSIBLE must be done for the patient. Your doctors will nod their heads and tell your family they respect their wishes. It will be a lie. Oh, sure, they will carry out the family’s wishes, in terms of continuing to provide the care. But respect? In the cafeteria at lunch, they will – despite medical confidentiality laws that totally prohibit this – compare stories of the most ridiculous families. “I have a blind 90 year old patient with stage 4 lung cancer with brain mets and no kidney function, and the family is demanding I enroll her in a clinical trial from Sri Lanka.” “Oh, that’s nothing. I'' have a patient who can’t walk or speak who’s breathing from a ventilator and has anoxic brain injury, and the family is insisting I try to get him a liver transplant.” Every day, your doctors will meet with your family another time, and eventually, as your condition worsens and your family has more time to be hit on the head with a big club marked ‘REALITY’, they will start to relent. Finally, they will allow your doctors to take you off of the machines, and you will be transferred to Palliative Care, whose job I do not envy even though ''every single palliative care doctor I have ever met is relentlessly cheerful and upbeat and this is a total mystery to me. And you will die, but not quickly. It takes time for the heart to give up, for the lungs to fill with water and stop breathing, for the toxic wastes to build up. It is generally considered wise for the patient to be on epic doses of morphine throughout the process, both to spare them the inevitable pain as their disease takes their course and to spare their family from having to watch them. …not that they always do. It can take anywhere from a day to several weeks for someone to die. Sometimes your family wants to wait at the bedside for a week. But a lot of the time they have work and things to do. Maybe they live thousands of miles away. You haven’t recognized them in years, you haven’t spoken a coherent word in months, and even if for some reason your brain chose this moment to recover lucidity you’re on enough morphine to be well inside the borders of la-la-land. A lot of families, faced with the prospect of missing work and school to sit by what’s basically a living corpse day in and day out for weeks just to watch it turn into a non-living corpse, politely decline. I absolutely 100% cannot blame them. There is a national volunteer program called No One Dies Alone. Nice people from the community go into hospitals to spend time with dying people who don’t have anyone else there for them. It makes me happy that this program exists. Nevertheless, this is the way many of my patients die. Old, limbless, bedridden, ulcerated, in a puddle of waste, gasping for breath, loopy on morphine, hopelessly demented, in a sterile hospital room with someone from a volunteer program who just met them sitting by their bed. And let me just emphasize again, not everyone dies this way. I am hugely selection biased by my position in a hospital. But enough people die this way. I’m in a small community. There can’t be too many deaths here. Of the ones there are, I see a lot of them. And they’re not pretty. ['''EDIT:' Just looked up statistics. Only about a quarter of old people die at home. The rest are split between hospitals (disproportionately ICUs), nursing homes, and hospices.]'' II. Hospital poetry is notoriously bad. I mean, practically all modern poetry is bad. Modern poetry by complete amateurs could be expected to be even worse. But hospital poetry is in a league all of its own as far as badness goes. When I search “hospital poetry”, Google brings up examples like the following: Pain… searing Belly… throbbing There is no baby. There will be no baby. Endometriosis. I feel bad making fun of it, because it is clearly heartfelt. This is part of the problem with hospital poetry. It is very heartfelt, whereas I think most popular poetry comes from people who have strong emotions but also some distance from them and a little bit of post-processing. And unfortunately doctors, who are on this decades-long quest to prove they are actual people with real feelings and not just arrogant robot-like people in white coats who know a very large number of facts about thyroiditis, just eat this sort of thing up. But I’m not really complaining about those sorts of endometriosis poems. The ones I’m really complaining about are worse. The epitome of the genre I can’t find on Google, because it was presented as some kind of event at the hospital where I trained in Ireland. I don’t remember it, but let me just make up some doggerel approximately faithful to the spirit of the original: When my doctor told me that I had cancer I knew that despair was not the answer It felt like the darkness was closing in But to give up would have been a sin Everyone here helped me so much And nothing is like a helping hand’s touch Thanks, Dr. Connell, and everyone in Cork I really appreciate all your hard work